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Meadow Lake Health Center
16044 Cr 165, Tyler, TX 75703 · CMS Certification Number (CCN) 676286
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At a glance
- CMS overall rating
- ★★★★★ 5 of 5
- Health inspection citations
- 4 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 1 from complaints)
- Fire safety citations
- 0
- Fines (last 3 years)
- 0 fines, total $0
- Payment denials
- 0
- Most recent standard inspection
- September 24, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★★★★ 5 of 5 | 2.7 | 3 |
| Health inspections | ★★★★★ 5 of 5 | 2.8 | 2.8 |
| Staffing | ★★★☆☆ 3 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★★★ 5 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★★★ 5 of 5 | Not published | Not published |
| Short-stay quality | ★★★★★ 5 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | September 24, 2025 | 0 | 0 | 0 |
| Cycle 2 | August 21, 2024 | 2 | 1 | 1 |
CMS weighted health inspection score: 2 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
4 health citations across 3 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
May 19, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 05/20/2025 |
August 21, 2024: 1 citation (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 08/22/2024 |
July 19, 2023: 2 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/20/2023 |
| E | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/20/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
No fire safety citations published for this facility in the CMS Fire Safety Deficiencies file.
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
No fines or payment denials published for this facility in the CMS Penalties file (last 3 years).
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 4.01 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.83 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.57 | Not published | Not published |
| Nurse aide hours per resident per day | 2.62 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.39 | Not published | Not published |
| RN hours per resident per day, weekends | 0.49 | Not published | Not published |
| Total nursing staff turnover (%) | 56.3 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 62.5 | Not published | Not published |
| Administrators who have left | 0 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Meadow Lake, LLC
- Ownership type
- Non profit - Corporation
- Chain
- Lifespace Communities (15 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 20
- Average residents per day
- 28.4
- Participates in
- Medicare
- Located inside a hospital
- No
- Continuing care retirement community
- Yes
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- May 31, 2011
- County/parish
- Smith
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
7 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| BELL, ROBBIN | W-2 MANAGING EMPLOYEE | Individual | NOT APPLICABLE | undefined undefined, NaN |
| JANTZEN, JESSE | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| GORMAN, JOSEPH | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HARSHFIELD, NICHOLAS | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| JANTZEN, JESSE | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| POPE, ERIN | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LIFESPACE COMMUNITIES INC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Meadow Lake Health Center. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.